Infection Control Today - 10/2003: Building Blocks

Building Blocks
Training and Educating the Next Generation of CS/SPD Personnel

By Kathy Dix

As reports of increased numbers of hospital-acquired infections make the news, the public has become aware of the role of central sterile (CS) and sterile processing (SP) staff members and their importance in keeping patients safe.

Some facilities look on CS/SP staff as glorified custodians, but others expect them to do everything but eradicate nosocomial infections single-handedly, an accomplishment as likely as solving the problem of world hunger and curing the common cold.

There are certain standards that do not vary from location to location; CS/SP personnel will always be expected to disinfect and sterilize reusable medical-surgical supplies; they will also need to know how to operate sterilizing units and how to monitor them for efficacy. However, other roles are more nebulous.

The Oklahoma Department of Career and Technology Education offers a lengthy description of the skill set for a central sterile processing employee.

Fulfilling so many requirements is a tall order. Accomplishing each item on such a long list requires an exceptional training and education program.

The biggest issue for training and education of CS personnel is having the resources, says Nancy Chobin, RN, CSPDM, central service/sterile processing department educator for St. Barnabas Health Care System in Livingston, N.J. She notes that CS is rarely allotted the resources that the OR and other departments receive.

“Very, very few — and I personally don’t know of any — CS departments have an educator. And if the operating room has one, they rarely have time to dedicate to sterile processing. They may provide education to CS staff, but it’s geared toward the operating room, so it doesn’t really help them grow and develop and get their continuing education,” Chobin says.

Often, Chobin notes, people will submit their applications for recertification, but they will list inservices on malignant hypothermia or a specific defibrillator. “I understand they need to have this in the OR, but it’s not applicable to them in SP,” she objects. “They’re frustrated because they can’t get the continuing education they need. Resources are very slanted on the side of the OR.”

Finding time to train staff in-house is another issue. “We can shut the operating room for an hour every week or two weeks for an inservice; you try to do that in CS! People would go berserk. And yet we need to provide the education and training there just as well,” she points out.

Chobin notes that processing has changed due to the introduction of minimally invasive surgery with its accompanying instrumentation. “Everyone has had to learn all new instrumentation, how to clean them, how to assemble them, what they are. And the second thing with instrumentation is the newer technology ... this is all state-of- the-art 22nd century technology, and yet nobody is concentrating on the people in CS who have to clean and sterilize these devices. You can’t support state-of-the-art technology when you’re still dealing with people and equipment that are based on the needs of 25 years ago.”

And oftentimes, people just don’t understand what CS does. “There are administrators who still think that CS hands out bedpans and thermometers,” Chobin says. “I’ve been in hospitals where they don’t even know where it’s located. I understand they’re busy people, but this is a critical department. Someone has got to get the message out there that if we don’t provide the resources and the education and the competency in that department, we’re going to have problems.”

In the past, perhaps because it is a newer department, CS has been the “orphan,” Chobin says. “We don’t make money for the hospital; we spend money. We are labor-intensive, but we don’t generate any income.” The fact that the CS department may be saving the hospital money in the long run — due to decreased nosocomial infections — is sometimes disregarded.

“There has to be a recognition of how important CS is,” she adds. “I know the OR goes, ‘Oh, those idiots; they don’t know what they’re doing; things are always wrong!’ But why? They are wrong because (the staff) haven’t been trained correctly, they don’t have the information they need.”

In the St. Barnabas system, the system has been revised to work proactively with the OR, CS and infection control departments. In other hospitals, those departments have worked with risk management and quality assurance as well. “And now it didn’t become a Hatfields and McCoys, just the OR against SPD. Now it became a committee decision ... So it can be done. It really requires a lot of time and a lot of effort,” she suggests.

Miscommunication is one of the most common problems, and that, too, can be traced to inadequate education on both sides. “On at least three occasions, I have been brought into hospitals where they were literally ready to fire everybody in CS and send the instruments out for reprocessing to a third-party company,” recalls Chobin. “In each case when I went in, the savings to the hospital by keeping it inside were astronomical as opposed to sending it out.” What Chobin found was that if the hospital took only half of what they were willing to for one year of outsourcing and put that money in central supply to upgrade the equipment, the department and provide education and training, it would create a well-oiled machine.

“You think the people they have at the outsourcing company came from a special mold?” she asks rhetorically. “They’re the same people that you’re hiring, only they make sure when they hire them that they’re trained and they’re certified. You should be doing the same thing. They don’t go to a special company and get these people. They’re the same people that you have, only that company was smart. They made sure the people they hired were knowledgeable and were going to do the job correctly.”

When asked if hospitals typically reimburse for continuing education and training, Chobin replies, “That’s the first thing that’s cut out of a budget, and that becomes another issue because the people in CS are some of the lowest paid people. There is something inherently wrong with healthcare when a person in McDonald’s can make more money than a person working in CS. It is absolutely wrong; in my opinion it’s morally wrong. These people have one of the most important jobs in the hospital. If I leave a pickle off a hamburger, nobody’s going to die, but if I screw up in CS and I don’t clean something correctly or I run it on the wrong cycle, you can have ramifications up to and including death.”

Facilitating Onsite Education

Many facilities have CS staff who are particularly proactive and will acquire education off-site on their own time, with their own money. But Chobin lauds the St. Barnabas system for its support and in-house education. The nine-hospital system is currently standardizing all its policies and procedures, product lines and training and education. “We are going to make sure that every single person in CS gets the same training; we’re going to make sure that they all are getting compensated for certification. (Some hospitals) have not recognized people who are certified; we are now going to push that they get recognized for certification, because if this person went on their own to take the time to train, to get educated and pass that exam, I want to keep that person. I’m not going to lose them because they can make 25 cents more at McDonald’s.”

The bottom line, Chobin stresses, is that the cost of a preceptor and an in-house program will more than make up for the cost of training replacement employees. “We have an average of 33 percent turnover nationwide in CS. At the end of 1997, the average cost to train a CS worker was $29,006,” she says.

“Let’s face it; here’s an ad: Apply for this job! You’ll be treated like crap, you’re going to get a low salary, you have to work holidays and weekends, you’re going to be treated inferiorly. Are you going to apply for that job? That’s basically what you’re asking these people to do,” adds Chobin. “They don’t get any respect, they don’t get any recognition, many of them are paid at the same level as housekeeping, and believe me, that is not a dig at housekeeping, but if I don’t clean a floor correctly, there’s a big difference between cleaning a floor and cleaning an instrument that’s going to be used inside my brain or inside my body.”

Respect and education can solve the problem, says Chobin. “When we don’t pay people appropriately, when we don’t recognize them for certification if they have taken the initiative ... of course, if this person can make more money elsewhere, they’re going to leave. I’ve lost the benefit of that person’s competency in my department. It’s probably going to cost me over $30,000 to train a new person, whereas for $3,000 I could have kept them here.”

She has seen improvement since certification began in 1991, but there are still facilities that do not recognize it or value the contribution of the SP department. The constant updates to technology can bring an overwhelming number of new instruments or procedures to CS staff. “If I work neurosurgery, I only have to know the neuro instruments. In CS, they have to know all of them. Where are you going to get that for $5.65 an hour?” Chobin points out.

“One of our hospitals in St. Barnabas starts at $14 an hour, but it’s a union hospital. But when you look at what we’re asking from these people, we can’t be paying them minimum wage or the same salary as housekeeping and expect them to do the work we’re expecting them to do. They have to have a decent salary to attract them; they need a career ladder. If you’re the manager and the only other job title is technician, I have to wait for you to retire or die to get a promotion. Not very good for my prospects! At least with a career ladder based on certification, we have entry-level; when they get certified they become a specialist. It’s a great title and adds to self-esteem, and they get $1 more an hour. Then they have an opportunity to become a lead technician, which requires certification, and they also have some management responsibilities. And then there’s a supervisor, who is an assistant to the manager. Now there’s someplace for them to grow.”

Chobin also notes that many more employees these days are single parents, and the extra money at another facility could be an irresistible draw to anyone pinching pennies. “We had a hospital here in New Jersey a number of years ago that was so desperate for staff that they raised their starting salaries by $4 an hour. We had a mass exodus. One hospital lost 75 percent of their staff to that other hospital. They were devastated,” she says.

“My feeling is, you can’t afford not to train; we can’t afford not to provide continuing education ... because these are the people who are sterilizing and cleaning the instruments that are going in babies, in your family members, and somebody better make sure they know what they’re doing. CS people don’t wake up in the morning and say, ‘Let me see how I can screw up the hospital today.’ They’re doing what they were told to do, and in many cases I find that was a technique from 30 years ago,” Chobin continues.

“It’s not their fault at all. You tell them what to do and these people will work their hearts out for you. But they’ve got to be given the information. They’re like sponges; when I speak at seminars, they absorb everything, they appreciate the education, they take it and they embrace it. There’s nothing more frustrating than somebody contacting me after a seminar and saying, ‘You know, Nancy, I went back and I told my supervisor what you said, and she said, “No, we don’t have to make that change. The OR will never go for it.”’ These are accepted standards of practice. Here they’ve taken the time to get educated and are told, ‘I don’t want to hear from you.’”

Chobin had one woman call her and ask, “Is there a law that would prevent a brand-new SP worker from being assigned to working the 3- 11 shift on a weekend by themselves with only three weeks’ experience?” Chobin was appalled. “You want to talk about a lawsuit; you want to talk about what we can do to hurt the patient?” Chobin had written an article on training, and her research showed that the average time to train a CS worker is 18 months. “And yet there were people who responded they only had three weeks; if you can’t learn in three weeks, tough!” she laments.

Convincing Administration

“In most cases, they’re not getting any education. Unfortunately, there’s no standardized formal education program on the job, and there are a very limited number of formal educational programs out there that these people have access to,” agrees Teckla Ann Maresca, LPN, CSPDM, the SP department manager at St. Clare’s Health System in Denville, N.J.

Some programs, although valuable, are simply too costly for the average CS employee, and although, as Maresca says, the SP employees are “some of the best, most dedicated caring employees that you’ll never want to meet,” many of them have not had any secondary education.

“They come into a field that demands the best, where they literally have the life and death of patients in their hands; they have control. They care a great deal; they’re under a lot of pressure; they’re put under a lot of stress, and yet they continue to do what is best for the patient.”

Although CS staff are sometimes maligned by other departments because they have less education, those departments “recognize the fact that this is a dedicated group of people with a lot of pride in what they do, so when they do receive proper training, they take pride in what they do and understand that what they do is critical to the outcome, that they do have a responsibility. But most of them don’t get that kind of intense training,” adds Maresca.

Maresca sees the solution in a standardized program that can be offered through community colleges. But it must be taught by instructors who are actually experienced at sterilization. “Their courses have to be geared towards what they’re doing; the principles of sterilization don’t come just from the book ... Unless you do the job every day, you can’t instruct somebody in sterilization. You can teach them principles, but they need more than that.”

And CS training differs from location to location, Maresca points out. “If you’re taking a course in intermediate basket weaving, from college to college it’s going to be the same program. With CS it goes from one extreme to another.” Simply reading the course outline is inadequate. Some of the existing programs will use in-house instructors who have no first-hand experience with sterile processing, and who also forget that not all the students come from the same educational and language backgrounds.

And even when employees did complete education, some administrations would not recognize the certification. Maresca’s facility has been very good, but she notes that St. Clare has been the exception, not the rule. A “career ladder” offered the ability to advance as team members acquired more certification and skills.

“Many institutions don’t have that,” she affirms. Facilities that reprocess in-house need to ensure that there is a possibility of advance, that education is provided, and that it is provided by appropriate instructors. Maresca’s goal of teaching and involvement in this field has always had the full support of her administration. “That’s probably why I’m still there, after 30 years,” she laughs. “I don’t know that they fully understood (the importance of CS staff) over the years, but they accepted it. For some reason they believed in us, and I think as the years go on they understand, more so now than they did before, what our importance is. But they’ve always believed in us.”

Ultimately, she concludes, “The important thing is they need to have administrations that support the need for education for their staff.”